The focus of this blog is on the wonders of government-run health-care everywhere but I also note the damage done to private medicine by a legal system that supports predatory litigation.

The long-established socialized medicine systems in Britain and Australia are a particularly relevant warning about where such systems end up.

Posts by John J. Ray (M.A.; Ph.D.)

Saturday, August 22, 2009

List of public hospitals with high death rates published by British regulator

A list of hospitals that have sparked safety alerts after unusually high numbers of patients died has been published by the NHS regulator. The Care Quality Commission (CQC) revealed details of all trusts where mortality rates were high enough to require a formal investigation in the past two years. Overall, there were 85 alerts that required investigations among trusts in England, but of those only seven were required to produce action plans to improve their care.

These included Mid Staffordshire NHS Foundation Trust, where an official report published in March found that appalling emergency care had led to between 400 and 1,200 patients dying needlessly.

The alerts, based on information from the Dr Foster Unit at Imperial College London and the CQC, are triggered if numbers of deaths among hospital patients admitted for particular conditions or procedures are significantly higher than expected.

The Department of Health said that it welcomed the publication of the data, which will be updated every three months. But Richard Lilford, Professor of Clinical Epidemiology at the University of Birmingham, said that the data revealed little about the quality of care. “We’re saying that these hospitals are bad apples. I don’t think the methodology is capable of doing that,” he told the Health Service Journal (HSJ).

The other trusts that required action plans were investigated in connection with their death rates in a range of patient groups, from newborn babies at University Hospitals of Leicester NHS Trust to adults with broken hips at Basingstoke and North Hampshire NHS Trust and Sheffield Teaching Hospitals Foundation Trust.

Death rates also triggered warnings among heart attack patients at Salisbury NHS Foundation Trust, those who suffered aneurysms at Pennine Acute Hospitals NHS Trust and septicaemia (blood poisoning) at Barking, Havering and Redbridge NHS Trust. Out of 45 alerts followed up with trusts, in 29 cases quality of care was not a concern, the HSJ reported.

Four in 10 local healthcare trusts are not funding medications which have been approved by the Government’s drugs rationing body, a new survey shows. Only 60 per cent say they routinely pay for drugs for leukaemia and other types of blood cancer that have been passed by the National Institute for Health and Clinical Excellence (Nice). Campaigners claim that patients are being let down by the system. One of the drugs not currently funded by all healthcare trusts, called rituximab, or mabtherma, was passed by Nice for use in the first relapse of a blood cancer called multiple myeloma as long ago as 2006.

Some of the drugs were only paid for after patients apply for “exceptional funding”, a route often used for drugs which have yet to be assessed by Nice, rather than those which have already been approved.

Tony Gavin, director of cancer campaigning at Leukaemia CARE, the charity which carried out the research, said: “We don’t know why this is happening but we are very concerned. “If this delays treatment for patients, that is time that some patients don’t have.”

Blood cancers are the fifth most common kind of the disease in Britain, with around 27,000 patients diagnosed every year. Around 7,200 cases of leukaemia alone are identified annually.

The report requested data from all of England’s 157 Primary Care Trusts, as well as their equivalent health boards in Wales. The charity received answers from 63 per cent of those asked.

Trusts have a legal obligation to pay for drugs which have been approved by Nice, although they can also choose to pay for medication which the rationing body is still in the process of assessing.

The charity has also called on Trusts to collect data on their compliant with Nice recommendations. Hilary Jackson, Cancer Research UK’s policy manager, said: “There seems to be some confusion about the need for local health providers to make NICE-approved drugs available - and a lack of consistency in the way that drugs that are still under review are used. "It is important we understand why NICE approved drugs aren't being made available. “Local health providers need better ways of measuring where and how new treatments are provided by the NHS. They should publish this information to make clear comparisons across the UK and PCTs should share best practice on how they make new drugs available.

“It is important that patients know that they will be able to access drugs that have been shown by NICE to be both clinically and cost effective, regardless of where in the country they live.”

A third of a million samples sent to National Health Service pathology laboratories were wrongly labelled in the past year, figures show, leading to 46 deaths or serious delay in treatment. Almost 366,000 specimens were mislabelled before they arrived at the pathology laboratories, figures obtained under the Freedom of Information Act disclose.

A total of 46 recorded cases over the past financial year where uncovered where “mislabelling was found to have been related either to a patient death or a significant delay in patient treatment”, said the survey of every NHS trust in Britain, undertaken by the Channel 4 programme, More4 News. Out of the 120 Trusts that replied, the programme also found that almost 12,000 samples were incorrectly labelled by pathology lab staff. Figures for the previous years were not disclosed.

Professor John Kay, a consultant for John Radcliffe Hospital, Oxford and a Royal College of Pathologists spokesman said the figures were concerning. “Most of those errors actually occurred because we are using hand written request cards, they then come into the laboratory, we have to copy type them and that's where these errors are coming into the system,” he told the programme.

“A small number of those examples, there will be really serious problems. “A good example of that are blood transfusions. If the specimen that comes into the laboratory is wrong then the blood product that goes out is going to be wrong and some of them will be important things, like the diagnosis of cancer."

A Department of Health spokesman said the NHS tested and reported on 700 million pathology samples every year and took patient safety “very seriously”. "The NHS makes every effort to reduce mislabelling errors and only a very tiny fraction of the total number of pathology tests carried out in English NHS laboratories in a year contributes to a serious adverse impact on patients,” he said. "Many of these labelling errors happen outside the laboratory, with very few the result of error inside labs, where bar codes are almost universally used for patient/sample identification.”

The NHS is currently promoting the use of electronic requests for laboratory tests and similar systems were also being deployed in hospitals, he added.

Canada: Thousands of surgeries may be cut in Metro Vancouver due to government underfunding, leaked paper

Vancouver patients needing neurosurgery, treatment for vascular diseases and other medically necessary procedures can expect to wait longer for care, NDP health critic Adrian Dix said Monday. Dix said a Vancouver Coastal Health Authority document shows it is considering chopping more than 6,000 surgeries in an effort to make up for a dramatic budgetary shortfall that could reach $200 million. “This hasn’t been announced by the health authority … but these cuts are coming,” Dix said, citing figures gleaned from a leaked executive summary of “proposed VCH surgical reductions.”

The health authority confirmed the document is genuine, but said it represents ideas only. “It is a planning document. It has not been approved or implemented,” said spokeswoman Anna Marie D’Angelo.

Dr. Brian Brodie, president of the BC Medical Association, called the proposed surgical cuts “a nightmare.” “Why would you begin your cost-cutting measures on medically necessary surgery? I just can’t think of a worse place,” Brodie said.

According to the leaked document, Vancouver Coastal — which oversees the budget for Vancouver General and St. Paul’s hospitals, among other health-care facilities — is looking to close nearly a quarter of its operating rooms starting in September and to cut 6,250 surgeries, including 24 per cent of cases scheduled from September to March and 10 per cent of all medically necessary elective procedures this fiscal year.

The plan proposes cutbacks to neurosurgery, ophthalmology, vascular surgery, and 11 other specialized areas. As many of 112 full-time jobs — including 13 anesthesiologist positions — would be affected by the reductions, the document says. “Clearly this will impact the capacity of the health-care system to provide care, not just now but in the future,” Dix said.

Further reductions in surgeries are scheduled during the Olympics, when the health authority plans to close approximately a third of its operating rooms.

Two weeks ago, Dix released a Fraser Health Authority draft communications plan listing proposed clinical care cuts, including a 10-per-cent cut in elective surgeries and longer waits for MRI scans. The move comes after the province acknowledged all health authorities together will be forced to cut staff, limit some services and increase fees to find $360 million in savings during the current fiscal year. In all, Fraser Health is looking at a $160-million funding shortfall.

D’Angelo said Vancouver Coastal’s deficit is closer to $90 million — almost a third of which ($23 million) has already been absorbed through reductions in non-clinical administration efficiencies.

Vancouver Coastal performed 67,000 surgeries last year, an increase of 6,500 surgeries over 2007. “What has now happened is that now our wait times are about 25 per cent lower than the provincial average,” D’Angelo said. “We have put a dent in that wait list.”

Brodie acknowledged surgical waiting times have dropped significantly in recent years, particularly for patients needing hip and joint replacements. He said the proposed cuts threaten those advancements. “It sounds like we are going backwards here,” he said.

Total health spending in British Columbia was $15.7 billion this year, up about four per cent over last year’s total of 15.1 billion, according to figures provided by the ministry of health.

Health Minister Kevin Falcon was unavailable for comment Monday on the proposed health-care cuts. A ministry spokesman said Falcon is away on his honeymoon until the end of August.

Elsewhere in British Columbia, the province will look to replace the head of the Interior Health Authority, Murray Ramsden, after he announced he will step down at the end of the year. Ramsden has said his decision to retire is not related to financial problems faced by the authority.

If President Obama wants to better understand why America's discomfort with end-of-life discussions threatens to derail his health-care reform, he might begin with his own Department of Veterans Affairs (VA). He will quickly discover how government bureaucrats are greasing the slippery slope that can start with cost containment but quickly become a systematic denial of care.

Last year, bureaucrats at the VA's National Center for Ethics in Health Care advocated a 52-page end-of-life planning document, "Your Life, Your Choices." It was first published in 1997 and later promoted as the VA's preferred living will throughout its vast network of hospitals and nursing homes. After the Bush White House took a look at how this document was treating complex health and moral issues, the VA suspended its use. Unfortunately, under President Obama, the VA has now resuscitated "Your Life, Your Choices."

Who is the primary author of this workbook? Dr. Robert Pearlman, chief of ethics evaluation for the center, a man who in 1996 advocated for physician-assisted suicide in Vacco v. Quill before the U.S. Supreme Court and is known for his support of health-care rationing.

"Your Life, Your Choices" presents end-of-life choices in a way aimed at steering users toward predetermined conclusions, much like a political "push poll." For example, a worksheet on page 21 lists various scenarios and asks users to then decide whether their own life would be "not worth living."

The circumstances listed include ones common among the elderly and disabled: living in a nursing home, being in a wheelchair and not being able to "shake the blues." There is a section which provocatively asks, "Have you ever heard anyone say, 'If I'm a vegetable, pull the plug'?" There also are guilt-inducing scenarios such as "I can no longer contribute to my family's well being," "I am a severe financial burden on my family" and that the vet's situation "causes severe emotional burden for my family."

When the government can steer vulnerable individuals to conclude for themselves that life is not worth living, who needs a death panel? One can only imagine a soldier surviving the war in Iraq and returning without all of his limbs only to encounter a veteran's health-care system that seems intent on his surrender.

I was not surprised to learn that the VA panel of experts that sought to update "Your Life, Your Choices" between 2007-2008 did not include any representatives of faith groups or disability rights advocates. And as you might guess, only one organization was listed in the new version as a resource on advance directives: the Hemlock Society (now euphemistically known as "Compassion and Choices").

This hurry-up-and-die message is clear and unconscionable. Worse, a July 2009 VA directive instructs its primary care physicians to raise advance care planning with all VA patients and to refer them to "Your Life, Your Choices." Not just those of advanced age and debilitated condition—all patients. America's 24 million veterans deserve better.

Many years ago I created an advance care planning document called "Five Wishes" that is today the most widely used living will in America, with 13 million copies in national circulation. Unlike the VA's document, this one does not contain the standard bias to withdraw or withhold medical care. It meets the legal requirements of at least 43 states, and it runs exactly 12 pages.

After a decade of observing end-of-life discussions, I can attest to the great fear that many patients have, particularly those with few family members and financial resources. I lived and worked in an AIDS home in the mid-1980s and saw first-hand how the dying wanted more than health care—they wanted someone to care.

If President Obama is sincere in stating that he is not trying to cut costs by pressuring the disabled to forgo critical care, one good way to show that commitment is to walk two blocks from the Oval Office and pull the plug on "Your Life, Your Choices." He should make sure in the future that VA decisions are guided by values that treat the lives of our veterans as gifts, not burdens.

Opponents of the Democrats' all-out push for healthcare legislation have been striking back hard. Some have condemned it as "socialized medicine," others have dissected it line by line to reveal its more egregious provisions, and still others have simply labeled it "deathcare" citing the sections of the bill calling for healthcare rationing and government death counselors. They have given the Democrat Party elites one opportunity after another to fight back with the "facts." But, instead, "Obamacare" apologists have hurled invective, launched carefully orchestrated smear campaigns, and cloistered themselves behind barricades to fend off peaceful protestors.

Speaker Nancy Pelosi (D-CA) and House Majority Leader Steny Hoyer (D-MD) penned a piece together over the weekend in which they called Obamacare opponents "un-American." And they even claimed, contrary to recent polling, that most Americans want the healthcare legislation they are proposing.

When Democrats have run into opposition from those they serve at town hall meetings, they have not shown the slightest inclination to seriously listen to those concerns. Sheila Jackson Lee, infamously talked on her cell phone while taking attendees' questions. Pelosi and Hoyer called concerned constituents "mobs" and "astroturf" (phony grassroots organizations).

And the White House isn't doing much better. A call for all citizens to send in the names of those who espouse "fishy" and "misleading" information about the healthcare legislation – "even in casual conversation" -- to the ominous sounding flag@whitehouse.gov has already sparked public outrage. And it has prompted one Senator to accuse the White House of creating lists of enemies.

Another White House call to its union cronies to "punch back twice as hard" on healthcare, may have played a direct role in the savage beating of an African American opponent of the plan. This beating was so severe that a local emergency room treated him for numerous injuries.

There have been some rather feeble attempts to sell it. Health and Human Services Secretary Kathleen Sebelius wrote two opinion pieces that were heavy on the lofty goals and good intentions of Democrat healthcare plans. But they fell far short on actual facts. In one of the pieces she went so far as to tell people that she and the President were taking care of the details, and that people should not "let the details distract [them] from the huge benefits reform will bring."

So, why aren't Democrat leaders trying harder to sell what is actually the warp and woof of their massive healthcare package? Because they have no intention of selling it. They talk of dialogue and then revile their opponents, without truly discussing the legislation or answering objections.

They have made up their minds on what is good for the country -- and regardless of any concerned constituents and their protests, as Mr. Obama has pointedly said time and again, they plan to enact their agenda. Come hell or high water. In short, every time the party leadership opens its mouth about healthcare, it is a simple extension of Obama's smug observation to Republicans in January: "I won. So live with it."

Well, they did win in 2008. But, as massive protests continue to build nationwide over the largest government power grab in recent U.S. history, there is a resounding question as to whether they will be able to say the same in 2010.

Over the past week, President Obama has held three town-halls to make the case for his health-care plan. While he didn't say much that he hasn't said a thousand times before, his remarks did offer another explanation for the public's skepticism of ObamaCare. Namely, the President contradicts himself every other breath. Consider: He likes to start off explaining our catastrophe of a health system. "What is truly scary—what is truly risky—is if we do nothing," he said in Portsmouth, New Hampshire. We can't "keep the system the way it is right now," he continued, while his critics are "people who want to keep things the way they are."

However, his supporters also want to keep things the way they are. "I keep on saying this but somehow folks aren't listening," Mr. Obama proclaimed in Grand Junction, Colorado. "If you like your health-care plan, you keep your health-care plan. Nobody is going to force you to leave your health-care plan. If you like your doctor, you keep seeing your doctor. I don't want government bureaucrats meddling in your health care."

Mr. Obama couldn't be more opposed to "some government takeover," as he put it in Belgrade, Montana. In New Hampshire, he added that people were wrong to worry "that somehow some government bureaucrat out there will be saying, well, you can't have this test or you can't have this procedure because some bean-counter decides that this is not a good way to use our health-care dollars."

So no bureaucrats, no bean-counters. Mr. Obama merely wants to create "a panel of experts, health experts, doctors, who can provide guidelines to doctors and patients about what procedures work best in what situations, and find ways to reduce, for example, the number of tests that people take" (New Hampshire, again). Oh, and your health-care plan? You can keep it, as long your insurance company or employer can meet all the new regulations Mr. Obama favors. His choice of verbs, in Montana, provides a clue about what that will mean: "will be prohibited," "will no longer be able," "we'll require" . . .

Maybe you're starting to fret about all those bureaucrats and bean-counters again. You shouldn't, according to Mr. Obama. "The only thing I would point is, is that Medicare is a government program that works really well for our seniors," he noted in Colorado. After all, as he said in New Hampshire, "If we're able to get something right like Medicare, then there should be a little more confidence that maybe the government can have a role—not the dominant role, but a role—in making sure the people are treated fairly when it comes to insurance."

The government didn't get Medicare right, though: Just ask the President. The entitlement is "going broke" (Colorado) and "unsustainable" and "running out of money" (New Hampshire). And it's "in deep trouble if we don't do something, because as you said, money doesn't grow on trees" (Montana).

So the health-care status quo needs top-to-bottom reform, except for the parts that "you" happen to like. Government won't interfere with patients and their physicians, considering that the new panel of experts who will make decisions intended to reduce tests and treatments doesn't count as government. But Medicare shows that government involvement isn't so bad, aside from the fact that spending is out of control—and that program needs top-to-bottom reform too.

Voters aren't stupid. The true reason ObamaCare is in trouble isn't because "folks aren't listening," but because they are.

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Background

Postings from Brisbane, Australia by John Ray (M.A.; Ph.D.) -- former member of the Australia-Soviet Friendship Society, former anarcho-capitalist and former member of the British Conservative party.

This blog gives a lot of attention to events in Australia and Britain -- places where there already exist systems similar to the one most likely to befall the USA if the Democrats get their way -- "Free" medical care supposedly available to all through government hospitals but with a competing private sector as well. The Canadian system is considered too Soviet to provide a likely model for the USA

TERMINOLOGY: Many of my posts concern the very instructive state of socialized medicine in Australia. Like the USA, Germany and India, Australia has a system of State governments which have substantial independence from the central (Federal) government and it is they who are mainly responsible for "free" health services. It may therefore be useful to some for me to note the standard abbreviations for the States concerned: QLD (Queensland), NSW (New South Wales), WA (Western Australia), VIC (Victoria), TAS (Tasmania), SA (South Australia).

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Conservatives do NOT object to helping the poor. Government welfare legislation in aid of the poor was in fact first introduced by conservatives -- Bismarck and Disraeli in the 19th century. What conservatives want is for the help to be delivered in a sane manner. And anyone who thinks that government bureaucracies can run hospitals well is completely out of touch with reality.

One of the oldest "free" public hospital systems in the world is that in the Australian State where I live: Queensland. It dates from 1944 (Britain's NHS began in 1948). So its advanced state of decay reveals well where the slow cancer of bureaucracy ends up. It now has three "administrative" employees for every medical employee. All those clerks are really good at curing people, I guess! Frequent bulletins on the flailing but ineffectual attempts to "fix" the system will appear here -- as well as bulletins on the dreadful things it does to patients and the long waits they endure.

On all my blogs, I express my view of what is important primarily by the readings that I select for posting. I do however on occasions add personal comments in italicized form at the beginning of an article.

I am rather pleased to report that I am a lifelong conservative. Out of intellectual curiosity, I did in my youth join organizations from right across the political spectrum so I am certainly not closed-minded and am very familiar with the full spectrum of political thinking. Nonetheless, I did not have to undergo the lurch from Left to Right that so many people undergo. At age 13 I used my pocket-money to subscribe to the "Reader's Digest" -- the main conservative organ available in small town Australia of the 1950s. I have learnt much since but am pleased and amused to note that history has since confirmed most of what I thought at that early age.

I imagine that the the RD is still sending mailouts to my 1950s address!

NOTE: The archives provided by blogspot below are rather inconvenient. They break each month up into small bits. If you want to scan whole months at a time, the backup archives will suit better. See here or here